079200389-9-13-2021-15-AS-KHOS-C73NEK-20210921102404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200389
Report Date: 09/13/2021
Date Signed: 09/13/2021 09:48:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2019 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20191101164746

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	CECILY PALMA		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 53	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cecily Palma, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of supervision resulting in resident pushing another resident sustaining an injury
Residents room has bed bugs
Staff left resident in soiled clothing for an extended period of time
Residents room and bathroom has feces
Staff not providing laundry service in a timely manner

INVESTIGATION FINDINGS:

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On 09/13/21 at 9AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent visit to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator (ADM) on the phone who was not at the facility during visit. ADM authorized acting supervisor to act on her behalf and sign the reports.

Allegation: Lack of supervision resulting in resident pushing another resident sustaining an injury
On 8/19/2021, LPA reviewed R1’s Physician’s Report dated 6/4/2019 and plan of care initiated on 11/11/2019. The Physician’s Report indicate that R1 is ambulatory. R1’s needs and services plan indicate R1 is independent with ambulation. The care plan also indicates that an escort is needed to/from activities and/or dining room. On 10/23/2019 when R1 was pushed by another resident which resulted to R1’s hairline fracture on the clavicle, Executive Director states it was an unwitnessed fall. A review of the incident report submitted to CCL states that S8 found R1 on the floor outside in the sitting area, Medication Technician was notified, 911 was called and responsible person and primary doctor were notified. Based on records reviewed and interview conducted, this allegation is unsubstantiated.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20191101164746

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HILLCREST MEMORY CARE LIVING	FACILITY NUMBER: 079200389
	VISIT DATE: 09/13/2021

NARRATIVE

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Allegation: Residents room has bed bugs - Unsubstantiated

On August 10, 2021, LPA interviewed Executive Director and obtained contract with pest control company and inspection report. Based on interview and records review conducted, facility has signed a contract with ZAP Termite and Pest Control, Inc on 12/1/2015. Director states that facility is still using the same company for pest control once a month. LPA obtained a copy of the inspection report dated 10/29/2019 which indicates that 43 rooms were inspected for bedbugs. The invoice also indicates that additional services for bedbugs was conducted for R1’s room. The pest control inspection was conducted two days prior to CCL receiving the above complaint. Based on interviews and records review conducted, the above allegation is unsubstantiated.

Allegation: Staff left resident in soiled clothing for an extended period of time. – Unsubstantiated

On 11/7/2019, LPA Praveen Singh interviewed S2 and S4. S4 states that staff check residents regularly to make sure residents are wearing clean clothes/diapers. S4 added that incontinent residents get checked and changed every hour, if needed. S2 states that staff gets incontinent residents to the toilet as frequent as possible especially after meals and before bedtime. And that caregivers observe residents for nonverbal cues which could be a sign that the resident needs to be toileted. Based on interviews conducted, the above allegation is unsubstantiated.

Allegation: Residents room and bathroom has feces - Unsubstantiated

On 11/7/2019, LPA Praveen Singh interviewed Staff 4 (S4) and former Executive Director Sonya Johnson. Johnson states that housekeeping comes twice a week. S4 states that caregivers clean the room and housekeepers sanitize. On 8/10/21, current Executive Director Cecily Palma provided LPA housekeeping schedule. Based on the schedule, Resident 1 (R1) room is scheduled for housekeeping every Tuesday and Sunday.

On 8/11/21, LPA Luisa Fontanilla interviewed Staff 7 (S7). S7 states that the caregivers maintain the rooms and housekeepers deep clean and sanitize. S7 states that R1’s room is being cleaned/sanitized every Tuesdays and Sundays and as needed. S7 added the rooms have been observed in good condition; meaning beds are made, bathrooms clean and floors have little debris. Based on interviews and records reviews conducted, this allegation is unsubstantiated.

Allegation: Staff not providing laundry service in a timely manner – Unsubstantiated

On 8/10/2021, LPA Luisa Fontanilla reviewed facility laundry schedule and interviewed Executive Director. Based on the facility’s laundry schedule and interview with Executive Director Cecily Palma, laundry comes once a week. R1’s laundry is scheduled every Tuesday. However, Director states that if clothes get soiled, they get washed immediately. Based on interview conducted by LPA Praveen Singh with Staff 2 (S2) on 11/7/2019, staff do the laundry on a weekly basis. However, if a resident is incontinent, soiled clothes get washed immediately. Staff do not wait until the end of the day or schedule to wash soiled clothes. Based on interviews and records reviews conducted, this allegation is unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2019 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20191101164746

FACILITY NAME:	HILLCREST MEMORY CARE LIVING		FACILITY NUMBER:	079200389
ADMINISTRATOR:	CECILY PALMA		FACILITY TYPE:	740
ADDRESS:	825 EAST 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 53	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cecily Palma, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff not safeguarding residents belongings

INVESTIGATION FINDINGS:

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On 09/13/21 at 9AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent visit to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator (ADM) on the phone who was not at the facility during visit. ADM authorized acting supervisor to act on her behalf and sign the reports.

Allegation: Staff not safeguarding residents belongings - Unfounded
On August 10, 2021, LPA Luisa Fontanilla interviewed Executive Director and obtained a copy of R1’s property inventory. LPA requested Director to conduct an inventory of R1’s belongings. LPA compared R1’s property inventory upon move in with current inventory. Based on the inventory document provided by Director to LPA, all R1’s belongings on the list except mattress are in R1’s room. Director states the mattress was picked up by R1’s family member when R1’s bed was replaced with a hospital bed. Based on interviews and records review, the above allegation is unfounded.

This department had investigated the complaint alleging that staff was not safeguarding residents belongings. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies cited. Exit Interview conducted and a copy of this report provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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